Provider Demographics
NPI:1346257599
Name:FORTGANG, ROBERTA COLE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:COLE
Last Name:FORTGANG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SOLON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1827
Mailing Address - Country:US
Mailing Address - Phone:617-964-6822
Mailing Address - Fax:617-964-6822
Practice Address - Street 1:50 SOLON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1827
Practice Address - Country:US
Practice Address - Phone:617-964-6822
Practice Address - Fax:617-964-6822
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10166881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04988OtherBLUE CROSS BLUE SHIELD